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Zou H, Chair SY, Feng B, Liu Q, Liu YJ, Cheng YX, Luo D, Wang XQ, Chen W, Huang L, Xianyu Y, Yang BX. A Social Media-Based Mindfulness Psycho-Behavioral Intervention (MCARE) for Patients With Acute Coronary Syndrome: Randomized Controlled Trial. J Med Internet Res 2024; 26:e48557. [PMID: 38376899 PMCID: PMC10915731 DOI: 10.2196/48557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 10/30/2023] [Accepted: 01/03/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Psychological distress is common among patients with acute coronary syndrome (ACS) and has considerable adverse impacts on disease progression and health outcomes. Mindfulness-based intervention is a promising complementary approach to address patients' psychological needs and promote holistic well-being. OBJECTIVE This study aims to examine the effects of a social media-based mindfulness psycho-behavioral intervention (MCARE) on psychological distress, psychological stress, health-related quality of life (HRQoL), and cardiovascular risk factors among patients with ACS. METHODS This study was a 2-arm, parallel-group randomized controlled trial. We recruited 178 patients (mean age 58.7, SD 8.9 years; 122/178, 68.5% male) with ACS at 2 tertiary hospitals in Jinan, China. Participants were randomly assigned to the MCARE group (n=89) or control group (n=89). The 6-week intervention consisted of 1 face-to-face session (phase I) and 5 weekly WeChat (Tencent Holdings Ltd)-delivered sessions (phase II) on mindfulness training and health education and lifestyle modification. The primary outcomes were depression and anxiety. Secondary outcomes included psychological stress, HRQoL, and cardiovascular risk factors (ie, smoking status, physical activity, dietary behavior, BMI, blood pressure, blood lipids, and blood glucose). Outcomes were measured at baseline (T0), immediately after the intervention (T1), and 12 weeks after the commencement of the intervention (T2). RESULTS The MCARE group showed significantly greater reductions in depression (T1: β=-2.016, 95% CI -2.584 to -1.449, Cohen d=-1.28, P<.001; T2: β=-2.089, 95% CI -2.777 to -1.402, Cohen d=-1.12, P<.001) and anxiety (T1: β=-1.024, 95% CI -1.551 to -0.497, Cohen d=-0.83, P<.001; T2: β=-0.932, 95% CI -1.519 to -0.346, Cohen d=-0.70, P=.002). Significantly greater improvements were also observed in psychological stress (β=-1.186, 95% CI -1.678 to -0.694, Cohen d=-1.41, P<.001), physical HRQoL (β=0.088, 95% CI 0.008-0.167, Cohen d=0.72, P=.03), emotional HRQoL (β=0.294, 95% CI 0.169-0.419, Cohen d=0.81, P<.001), and general HRQoL (β=0.147, 95% CI 0.070-0.224, Cohen d=1.07) at T1, as well as dietary behavior (β=0.069, 95% CI 0.003-0.136, Cohen d=0.75, P=.04), physical activity level (β=177.542, 95% CI -39.073 to 316.011, Cohen d=0.51, P=.01), and systolic blood pressure (β=-3.326, 95% CI -5.928 to -0.725, Cohen d=-1.32, P=.01) at T2. The overall completion rate of the intervention (completing ≥5 sessions) was 76% (68/89). Positive responses to the questions of the acceptability questionnaire ranged from 93% (76/82) to 100% (82/82). CONCLUSIONS The MCARE program generated favorable effects on psychological distress, psychological stress, HRQoL, and several aspects of cardiovascular risk factors in patients with ACS. This study provides clues for guiding clinical practice in the recognition and management of psychological distress and integrating the intervention into routine rehabilitation practice. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2000033526; https://www.chictr.org.cn/showprojEN.html?proj=54693.
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Affiliation(s)
- Huijing Zou
- School of Nursing, Wuhan University, Wuhan, China
| | - Sek Ying Chair
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Bilong Feng
- Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Qian Liu
- School of Nursing, Wuhan University, Wuhan, China
| | - Yu Jia Liu
- School of Nursing, Wuhan University, Wuhan, China
| | - Yu Xin Cheng
- School of Nursing, Wuhan University, Wuhan, China
| | - Dan Luo
- School of Nursing, Wuhan University, Wuhan, China
| | | | - Wei Chen
- School of Nursing, Wuhan University, Wuhan, China
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Zou H, Chair SY, Luo D, Liu Q, Wang XQ, Yang BX. A mindfulness-oriented psycho-behavioral intervention for patients with acute coronary syndrome: A pilot study. Heart Lung 2023; 62:240-248. [PMID: 37611384 DOI: 10.1016/j.hrtlng.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/15/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND People frequently experience physical and psychological challenges (e.g., depression and anxiety) and high risk of poor prognosis after an acute coronary event. Mindfulness-based intervention holds promise as an effective approach to promoting health and well-being. OBJECTIVES To explore the feasibility, acceptability, and potential effects on psychological distress, cardiovascular risk factors and health-related quality of life of a mindfulness-oriented psycho-behavioral intervention for patients with acute coronary syndrome. METHODS We conducted a pilot randomized controlled trial to test the feasibility, acceptability and potential effects of the intervention in 50 patients with acute coronary syndrome. The intervention included six weekly sessions, including one face-to-face session and five WeChat-delivered sessions that incorporated mindfulness training with health education and lifestyle modification. Eligible patients were recruited in two public hospitals in China and randomly allocated into the intervention group (n = 25) or control group (n = 25). RESULTS Intervention feasibility was supported by a relatively high recruitment rate (66.7%) and retention rate (84%) and a smooth and brief data collection procedure (15 to 25 min) of the pilot study. Positive responses of the acceptability dichotomous scale ranged from 81% to 100%, suggesting the intervention was generally acceptable. The intervention had a significant group × time effect on dietary behavior (B = 0.31,95% CI: 0.08, 0.54, P = 0.008) with an effect size (Cohen's d) of -0.72. CONCLUSIONS The mindfulness-oriented psycho-behavioral intervention appears to be feasible and acceptable and have a promising effect on dietary behavior in patients with acute coronary syndrome. A fully powered randomized controlled trial is warranted to further assess the efficacy of the intervention. TRIAL REGISTRATION Chinese Clinical Trial Registry, No., ChiCTR2000033526.
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Affiliation(s)
- Huijing Zou
- School of Nursing, Wuhan University, Building 2, No. 115 Donghu Road, Wuchang District, Wuhan 430071, China
| | - Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Dan Luo
- School of Nursing, Wuhan University, Building 2, No. 115 Donghu Road, Wuchang District, Wuhan 430071, China
| | - Qian Liu
- School of Nursing, Wuhan University, Building 2, No. 115 Donghu Road, Wuchang District, Wuhan 430071, China
| | - Xiao Qin Wang
- School of Nursing, Wuhan University, Building 2, No. 115 Donghu Road, Wuchang District, Wuhan 430071, China
| | - Bing Xiang Yang
- School of Nursing, Wuhan University, Building 2, No. 115 Donghu Road, Wuchang District, Wuhan 430071, China.
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Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
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Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
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Cognitive Function and the Relationship With Health Literacy and Secondary Prevention in Patients With Acute Coronary Syndrome at Early Discharge: A Prospective Observational Study. J Cardiovasc Nurs 2023; 38:E1-E11. [PMID: 36508239 DOI: 10.1097/jcn.0000000000000865] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cognitive impairment (CI) may contribute to difficulties in understanding and implementing secondary prevention behavior change after acute coronary syndrome (ACS), but the association is poorly understood. OBJECTIVES The aim of this study was to explore the prevalence of CI in patients 4 weeks post ACS and the association with health literacy and secondary prevention. METHODS Patients with ACS who were free from visual deficits, auditory impairment, and dementia diagnoses were recruited and assessed 4 weeks post discharge for cognitive function (Montreal Cognitive Assessment and Hopkins Verbal Learning Test), health literacy (Newest Vital Sign), depression (Patient Health Questionnaire), physical activity (Fitbit Activity Tracker and Physical Activity Scale for the Elderly), and medication knowledge and adherence. RESULTS Participants (n = 45) had an average age of 65 ± 11 years, 82% were male, 64% were married/partnered, and 82% had high school education or higher. Overall CI was identified in 28.9% (n = 13/45) of the patients 4 weeks after discharge, which was composed of patients detected on both the Montreal Cognitive Assessment and Hopkins Verbal Learning Test (n = 3), patients detected on Montreal Cognitive Assessment alone (n = 6), and patients detected on Hopkins Verbal Learning Test alone (n = 4). Fewer patients with CI had adequate health literacy (61.4%) than patients with normal cognition (90.3%, P = .024). Significant correlations were found between Hopkins Verbal Learning Test scores and medication knowledge (0.4, P = .008) and adherence (0.33, P = .029). CONCLUSIONS In this exploratory study, 30% of patients with ACS demonstrated CI at 4 weeks post discharge. Two screening instruments were required to identify all cases. Cognitive impairment was significantly associated with health literacy and worth further investigation.
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Pedersen CG, Nielsen CV, Lynggaard V, Zwisler AD, Maribo T. The patient education strategy "learning and coping" improves adherence to cardiac rehabilitation in primary healthcare settings: a pragmatic cluster-controlled trial. BMC Cardiovasc Disord 2022; 22:364. [PMID: 35941553 PMCID: PMC9361528 DOI: 10.1186/s12872-022-02774-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background Adherence and completion of programmes in educational and physical exercise sessions is essential in cardiac rehabilitation (CR) to obtain the known benefits on morbidity, mortality, risk factors, lifestyle, and quality of life. The patient education strategy “Learning and Coping” (LC) has been reported to positively impact adherence and completion in a hospital setting. It is unknown if LC has impact on adherence in primary healthcare settings, and whether LC improves self-management. The aim of this pragmatic primary healthcare-based study was to examine whether patients attending CR based on LC had a better adherence to patient education and physical exercise, higher program completion rate, and better self-management compared to patients attending CR based on a consultation program Empowerment, Motivation and Medical Adherence (EMMA).
Method A pragmatic cluster-controlled trial of two types of patient education LC and EMMA including ten primary healthcare settings and 514 patients (LC, n = 266; EMMA, n = 248) diagnosed with ischaemic heart disease discharged from hospital and referred to CR between August 1, 2018 and July 31, 2019. Adherence was defined as participation in ≥ 75% of provided sessions. Completion was defined as patients attended the final interview at the end of the 12-weeks programme. Patient Activation Measure (PAM) was used to obtain information on a person's knowledge, skills and confidence for self-management. PAM questionnaire was completed at baseline and 12-weeks follow-up. Multiple and Linear regression analyses adjusted for potential confounder variables and cluster effect were performed. Result Patients who followed CR based on LC had a higher adherence rate to educational and physical exercise sessions compared to patients who followed CR based on EMMA (p < 0.01). High-level of completion was found at the end of CR with no statistically significant between clusters (78.9% vs. 78.2%, p > 0.05). At 12-weeks, there was no statistical differences in PAM-score between clusters (p > 0.05). Conclusion This study indicates that the LC positively impacts adherence in CR compared to EMMA. We found non-significant difference in completing CR and in patient self-management between the two types of patient education. Future studies are needed to investigate if the higher adherence rate achieved by LC in primary healthcare settings translates into better health outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02774-8.
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Affiliation(s)
- Charlotte Gjørup Pedersen
- Department of Public Health, Aarhus University, Aarhus, Denmark. .,DEFACTUM, Central Denmark Region, Aarhus, Denmark. .,REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Claus Vinther Nielsen
- Department of Public Health, Aarhus University, Aarhus, Denmark.,DEFACTUM, Central Denmark Region, Aarhus, Denmark.,Department of Clinical Social Medicine and Rehabilitation, Gødstrup Hospital, Herning, Denmark
| | - Vibeke Lynggaard
- Cardiovascular Research Unit, Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | - Ann Dorthe Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Thomas Maribo
- Department of Public Health, Aarhus University, Aarhus, Denmark.,DEFACTUM, Central Denmark Region, Aarhus, Denmark
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Svendsen ML, Gadager BB, Stapelfeldt CM, Ravn MB, Palner SM, Maribo T. To what extend is socioeconomic status associated with not taking up and dropout from cardiac rehabilitation: a population-based follow-up study. BMJ Open 2022; 12:e060924. [PMID: 35728905 PMCID: PMC9214391 DOI: 10.1136/bmjopen-2022-060924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES High socioeconomic status (SES) has been linked to high referral for cardiac rehabilitation (CR). However, the impact of SES on CR utilisation from enrolment to completion is unclear. The objective of this study was to examine whether indicators of SES are associated with not taking up and dropout from CR. DESIGN A population-based, follow-up study. SETTING Hospitals and primary healthcare centres in the Central Denmark Region. PARTICIPANT Patients diagnosed with ischaemic heart disease (IHD) in the hospital and referred for rehabilitation in the primary healthcare setting from 1 September 2017 to 31 August 2018 (n=2018). VARIABLES Four SES indicators (education, disposable family income, occupation and cohabitant status) were selected because of their established association with cardiovascular health and CR utilisation. Patients were followed up regarding no uptake of or dropout from CR in the primary healthcare setting. STATISTICAL METHODS The associations between the four SES indicators and either no uptake or dropout from CR were analysed using logistic regression with adjustment for age, sex, nationality and comorbidity. RESULTS Overall, 25% (n=507) of the referred patients did not take up CR and 24% (n=377) of the participators dropped out the CR. All adjusted ORs, except one (education/dropout) demonstrated that low SES compared with high are statistically significantly associated with higher odds of not taking up CR and dropout from CR. The ORs ranged from 1.52, 95% CI 1.13 to 2.04 (education/no uptake) to 2.36, 95% CI 1.60 to 3.46 (occupation/dropout). CONCLUSIONS This study highlights that indicators of SES are important markers of CR utilisation following hospitalisation for IHD.
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Affiliation(s)
| | - Birgitte Bitsch Gadager
- DEFACTUM, Central Denmark Region, Aarhus, Denmark
- Centre for Rehabilitation Research, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Christina M Stapelfeldt
- DEFACTUM, Central Denmark Region, Aarhus, Denmark
- Centre for Rehabilitation Research, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Maiken Bay Ravn
- DEFACTUM, Central Denmark Region, Aarhus, Denmark
- Centre for Rehabilitation Research, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Sanne Moeller Palner
- Unit of Rehabilitation, Randers Health Centre, Randers Municipality, Randers, Denmark
| | - Thomas Maribo
- DEFACTUM, Central Denmark Region, Aarhus, Denmark
- Centre for Rehabilitation Research, Department of Public Health, Aarhus University, Aarhus, Denmark
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Ding EY, Mehawej J, Abu H, Lessard D, Saczynski JS, McManus DD, Kiefe CI, Goldberg RJ. Cardiovascular Health Metrics in Patients Hospitalized with an Acute Coronary Syndrome. Am J Med 2021; 134:1396-1402.e1. [PMID: 34273284 PMCID: PMC8605989 DOI: 10.1016/j.amjmed.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Life's Simple 7 (LS7) is a guiding metric for primordial/primary prevention of cardiovascular disease. However, little is known about the prevalence and distribution of LS7 metrics in patients with an acute coronary syndrome at the time of hospitalization. METHODS Data were obtained from patients hospitalized for an acute coronary syndrome at 6 hospitals in Central Massachusetts and Georgia (2011-2013). The LS7 assessed patient's smoking, diet, and physical activity based on self-reported measures, and patients' body mass index, blood pressure, and serum cholesterol and glucose levels were abstracted from medical records. All items were operationalized into 3 categories: poor (0), intermediate (1), or ideal (2). A total summary cardiovascular health score (0-14) was obtained and categorized into tertiles (0-5, 6-7, and 8-14). RESULTS The average age of study participants (n = 1110) was 59.6 years and 35% were women. Cardiovascular health scores ranged from 0-12 (mean = 6.2). Patients with higher scores were older, white, had lower burden of comorbidities, had fewer symptoms of anxiety, depression, and stress, better quality of life, more social support, and greater healthcare activation. One-third of patients had only 1 ideal cardiovascular health measure, less than 1% had 5, and no participant had more than 5 ideal factors. CONCLUSIONS Our results indicate that patients with acute coronary syndrome have poor cardiovascular health. Sociodemographic, clinical, and psychosocial characteristics differed across cardiovascular health groups. These findings highlight potential areas for educational and therapeutic interventions to reduce the risk of cardiovascular disease and promote cardiovascular health in adult men and women.
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Affiliation(s)
- Eric Y Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester.
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Hawa Abu
- Department of Medicine, St. Vincent's Hospital, Worcester, Mass
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Mass
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
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Chen J, Kiefe CI, Gagnier M, Lessard D, McManus D, Wang B, Houston TK. Non-specific pain and 30-day readmission in acute coronary syndromes: findings from the TRACE-CORE prospective cohort. BMC Cardiovasc Disord 2021; 21:383. [PMID: 34372783 PMCID: PMC8351351 DOI: 10.1186/s12872-021-02195-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/27/2021] [Indexed: 12/26/2022] Open
Abstract
Background Patients with acute coronary syndromes often experience non-specific (generic) pain after hospital discharge. However, evidence about the association between post-discharge non-specific pain and rehospitalization remains limited. Methods We analyzed data from the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) prospective cohort. TRACE-CORE followed patients with acute coronary syndromes for 24 months post-discharge from the index hospitalization, collected patient-reported generic pain (using SF-36) and chest pain (using the Seattle Angina Questionnaire) and rehospitalization events. We assessed the association between generic pain and 30-day rehospitalization using multivariable logistic regression (N = 787). We also examined the associations among patient-reported pain, pain documentation identified by natural language processing (NLP) from electronic health record (EHR) notes, and the outcome. Results Patients were 62 years old (SD = 11.4), with 5.1% Black or Hispanic individuals and 29.9% women. Within 30 days post-discharge, 87 (11.1%) patients were re-hospitalized. Patient-reported mild-to-moderate pain, without EHR documentation, was associated with 30-day rehospitalization (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.14–3.62, reference: no pain) after adjusting for baseline characteristics; while patient-reported mild-to-moderate pain with EHR documentation (presumably addressed) was not (OR: 1.23, 95% CI: 0.52–2.90). Severe pain was also associated with 30-day rehospitalization (OR: 3.16, 95% CI: 1.32–7.54), even after further adjusting for chest pain (OR: 2.59, 95% CI: 1.06–6.35). Conclusions Patient-reported post-discharge generic pain was positively associated with 30-day rehospitalization. Future studies should further disentangle the impact of cardiac and non-cardiac pain on rehospitalization and develop strategies to support the timely management of post-discharge pain by healthcare providers. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02195-z.
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Affiliation(s)
- Jinying Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | | | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
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Hajduk AM, Saczynski JS, Tsang S, Geda ME, Dodson JA, Ouellet GM, Goldberg RJ, Chaudhry SI. Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction According to Cognitive Status: The SILVER-AMI Study. Am J Med 2021; 134:910-917. [PMID: 33737057 PMCID: PMC8243828 DOI: 10.1016/j.amjmed.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors' risk for these outcomes is limited. METHODS 3041 patients aged ≥75 years hospitalized with acute myocardial infarction (mean age 82 ± 5 years, 56% male) recruited from 94 US hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment, respectively. Readmissions and death at 6 months post-discharge were ascertained via participant report and medical record review. Associations between cognition and outcomes were evaluated with multivariable-adjusted logistic regression. RESULTS Mild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort, respectively. Readmission and death at 6 months occurred in 41% and 9% of participants, respectively. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (odds ratio [OR] 1.36; 95% confidence interval [CI], 1.08-1.72 and OR 1.58; 95% CI, 1.18-2.12, respectively) and death (OR 2.19; 95% CI, 1.54-3.11 and OR 3.82; 95% CI, 2.63-5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death (OR 1.69; 95% CI, 1.10-2.59) persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression, but not for readmissions. CONCLUSIONS Moderate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes who may benefit from closer oversight and support in the post-discharge period.
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Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn.
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Science, Northeastern School of Pharmacy, Boston, Mass
| | - Sui Tsang
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Mary E Geda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY
| | - Gregory M Ouellet
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Sarwat I Chaudhry
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3047] [Impact Index Per Article: 1015.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Zou H, Cao X, Chair SY. A systematic review and meta-analysis of mindfulness-based interventions for patients with coronary heart disease. J Adv Nurs 2021; 77:2197-2213. [PMID: 33433036 DOI: 10.1111/jan.14738] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/28/2020] [Accepted: 12/10/2020] [Indexed: 12/25/2022]
Abstract
AIMS To assess the effects of mindfulness-based interventions for patients with coronary heart disease. DESIGN A systematic review with meta-analysis. DATA SOURCES Eight mainstream databases, including Ovid MEDLINE, Embase, Ovid Emcare, PsycInfo, CINAHL complete, Web of Science, CENTRAL and PubMed, were searched from January 1979-March 2020. REVIEW METHODS Randomized controlled trials that evaluated mindfulness-based interventions on psychological outcomes, cardiovascular risk factors and quality of life in adults with coronary heart disease were considered. We conducted meta-analyses using the random-effects model. RESULTS Nine studies involving 644 participants were included. Compared with inactive controls (e.g. usual care), mindfulness-based interventions significantly reduced depression (SMD -0.72, 95% CI -1.23 to -0.21, p < .01) and stress (SMD -0.67, 95% CI -1.00 to -0.34, p < .01), but not anxiety and blood pressure. There were no significant psychological effects compared with active controls (e.g. other psychological interventions). In one of three studies that assessed generic quality of life, mindfulness-based interventions significantly improved psychological and social domains compared with active control. The intervention effects on other cardiovascular risk factors were inconclusive given that only one study assessed each outcome with non-significant findings. Subgroup analyses suggest that intervention type and participants' depression and anxiety status may influence intervention effects. CONCLUSIONS Mindfulness-based interventions may benefit patients with coronary heart disease in reducing depression and stress, but the effects on cardiovascular risk factors and quality of life are inconclusive. IMPACT This review offers preliminary evidence for the potential of mindfulness-based interventions as an effective complementary approach to addressing psychological distress among people with coronary heart disease. Given the limitations in current studies, further rigorously designed and well-reported research is necessary to give robust evidence. Studies exploring the intervention effects on cardiovascular risk factors and quality of life are warranted to remedy the research and knowledge gap.
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Affiliation(s)
- Huijing Zou
- Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xi Cao
- Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sek Ying Chair
- Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR, China
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12
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Abu HO, McManus DD, Kiefe CI, Goldberg RJ. Religiosity and Patient Activation Among Hospital Survivors of an Acute Coronary Syndrome. J Gen Intern Med 2020; 35:762-769. [PMID: 31677101 PMCID: PMC7080940 DOI: 10.1007/s11606-019-05345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Optimum management after an acute coronary syndrome (ACS) requires considerable patient engagement/activation. Religious practices permeate people's lives and may influence engagement in their healthcare. Little is known about the relationship between religiosity and patient activation. OBJECTIVE To examine the association between religiosity and patient activation in hospital survivors of an ACS. DESIGN Secondary analysis using baseline data from Transitions, Risks, and Actions in Coronary Events: Center for Outcomes Research and Education (TRACE-CORE) Study. PARTICIPANTS A total of 2067 patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011-2013). MAIN MEASURES Study participants self-reported three items assessing religiosity-strength and comfort from religion, making petition prayers, and awareness of intercessory prayers for health. Patient activation was assessed using the 6-item Patient Activation Measure (PAM-6). Participants were categorized as either having low (levels 1 and 2) or high (levels 3 and 4) activation. RESULTS The mean age of study participants was 61 years, 33% were women, and 81% were non-Hispanic White. Approximately 85% derived strength and comfort from religion, 61% prayed for their health, and 89% received intercessory prayers for their health. Overall, 58% had low activation. Reports of a great deal (aOR, 2.02; 95% CI, 1.44-2.84), and little/some (aOR, 1.45; 95% CI, 1.07-1.98) strength and comfort from religion were associated with high activation, as were receipt of intercessions (aOR, 1.48; 95% CI, 1.07-2.05). Praying for one's health was associated with low activation (aOR, 0.78; 95% CI, 0.61-0.99). CONCLUSIONS Most ACS survivors acknowledge religious practices toward their recovery. Strength and comfort from religion and intercessory prayers for health were associated with high patient activation. Petition prayers for health were associated with low activation. Healthcare providers should use knowledge about patient's religiosity to enhance patient engagement in their care.
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Affiliation(s)
- Hawa O Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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13
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4793] [Impact Index Per Article: 1198.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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14
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5289] [Impact Index Per Article: 1057.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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Zhao E, Lowres N, Woolaston A, Naismith SL, Gallagher R. Prevalence and patterns of cognitive impairment in acute coronary syndrome patients: A systematic review. Eur J Prev Cardiol 2019; 27:284-293. [PMID: 31645116 DOI: 10.1177/2047487319878945] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimising risk factors through secondary prevention behaviour is challenging for patients following an acute coronary syndrome. Cognitive impairment can potentially make these changes more difficult. However, cognitive impairment prevalence in acute coronary syndrome patients is poorly understood. DESIGN This study was based on a systematic review. METHODS A systematic review was conducted of PubMed, Medline, PsycINFO and Cochrane databases up to March 2019, to identify studies reporting the prevalence of cognitive impairment in acute coronary syndrome patients. Predefined inclusion criteria were specified, including use of a validated cognitive impairment screening tool. Studies were excluded if patients had diagnosed dementia or coronary artery bypass graft surgery. Strengthening The Reporting of Observational Studies in Epidemiology and Cochrane Risk of Bias tools were used to assess quality. RESULTS From 747 potential studies, nine were included. The total sample size was 6457 (range 53-2174), mean age range was 51.3-77.4 years, and range of proportions of males was 57-100%. Reported cognitive impairment prevalence rates varied substantially (9-85%) with no clear pattern over time. From the two studies which examined domains, verbal fluency, memory and language were affected the most. Meta-analysis could not be undertaken due to diverse screening tools (n = 9), cut-off scores and screening timepoints. CONCLUSIONS Cognitive impairment in acute coronary syndrome patients is currently poorly described, and likely affects a substantial number of acute coronary syndrome patients who remain undetected and have the potential to develop to dementia in the future. As domains are most affected, this could impact understanding and retention of health education. Research is needed to accurately determine the prevalence of cognitive impairment in acute coronary syndrome patients and create suitable standardised measures and thresholds.
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Affiliation(s)
- Emma Zhao
- Charles Perkins Centre, University of Sydney, Australia.,Sydney Nursing School, University of Sydney, Australia
| | - Nicole Lowres
- Charles Perkins Centre, University of Sydney, Australia.,Stroke Prevention, Heart Research Institute, Sydney, Australia
| | | | - Sharon L Naismith
- Charles Perkins Centre, University of Sydney, Australia.,Healthy Brain Ageing Program, Brain and Mind Centre, University of Sydney, Australia
| | - Robyn Gallagher
- Charles Perkins Centre, University of Sydney, Australia.,Stroke Prevention, Heart Research Institute, Sydney, Australia
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16
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Religious practices and long-term survival after hospital discharge for an acute coronary syndrome. PLoS One 2019; 14:e0223442. [PMID: 31584980 PMCID: PMC6777785 DOI: 10.1371/journal.pone.0223442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/20/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Prior studies of healthy populations have found religious practices to be associated with survival. However, no contemporary studies have examined whether religiosity influences survival among patients discharged from the hospital after an acute coronary syndrome (ACS). The present study examined the relationship between religious practices and 2-year all-cause mortality among hospital survivors of an ACS. METHODS Patients hospitalized for an ACS were recruited from 6 medical centers in Massachusetts and Georgia between 2011 and 2013. Study participants self-reported three items assessing religiosity: strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. All cause-mortality within 2-years of hospital discharge was ascertained by review of medical records at participating study hospitals and from death certificates. Cox proportional hazards models were used to estimate the multivariable adjusted risk of 2-year all-cause mortality. RESULTS Participants (n = 2,068) were on average 61 years old, 34% were women, and 81% were non-Hispanic White. Approximately 85% derived strength/comfort from religion, 61% prayed for their health, and 89% were aware of intercessions. Overall, 6% died within 2 years post-discharge. After adjusting for sociodemographic variables (age, sex, and race/ethnicity), petition prayers were associated with an increased risk of 2-year all-cause mortality (HR: 1.64; 95% CI: 1.01-2.66). With further adjustment for several clinical and psychosocial measures, this association was no longer statistically significant. Strength and comfort from religion and intercessory prayers were not significantly associated with mortality. CONCLUSIONS Most ACS survivors acknowledge deriving strength and comfort from religion, praying for their health, and intercessions made by others for their health. Although the reported religious practices were not associated with post-discharge survival after multivariable adjustment, acknowledging that patients utilize their religious beliefs and practices as strategies to improve their health would ensure a more holistic approach to patient management and promote cultural competence in healthcare.
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17
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Survivors of an Acute Coronary Syndrome With Lower Patient Activation Are More Likely to Experience Declines in Health-Related Quality of Life. J Cardiovasc Nurs 2019; 33:168-178. [PMID: 28574974 DOI: 10.1097/jcn.0000000000000429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patient activation comprises the knowledge, skills, and confidence for self-care and may lead to better health outcomes. OBJECTIVES We examined the relationship between patient activation and changes in health-related quality of life (HRQOL) after hospitalization for an acute coronary syndrome (ACS). METHODS We studied patients from 6 medical centers in central Massachusetts and Georgia who had been hospitalized for an ACS between 2011 and 2013. At 1 month after hospital discharge, the patients completed the 6-item Patient Activation Measure and were categorized into 4 levels of activation. Multinomial logistic regression analyses compared activation level with clinically meaningful changes (≥3.0 points, generic; ≥10.0 points, disease-specific) in generic physical (SF-36v2 Physical Component Summary [PCS]), generic mental (SF-36v2 Mental Component Summary [MCS]), and disease-specific (Seattle Angina Questionnaire [SAQ]) HRQOL from 1 to 3 and 1 to 6 months after hospitalization, adjusting for potential sociodemographic and clinical confounders. RESULTS The patients (N = 1042) were, on average, 62 years old, 34% female, and 87% non-Hispanic white. A total of 10% were in the lowest level of activation. The patients with the lowest activation had 1.95 times (95% confidence interval, 1.05-3.62) and 2.18 times (95% confidence interval, 1.17-4.05) the odds of experiencing clinically significant declines in MCS and SAQ HRQOL, respectively, between 1 and 6 months than the most activated patients. The patient activation level was not associated with meaningful changes in PCS scores. CONCLUSIONS Hospital survivors of an ACS with lower activation may be more likely to experience declines in mental and disease-specific HRQOL than more-activated patients, identifying a group at risk of poor outcomes.
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Tran H, Byatt N, Erskine N, Lessard D, Devereaux RS, Saczynski J, Kiefe C, Goldberg R. Impact of anxiety on the post-discharge outcomes of patients discharged from the hospital after an acute coronary syndrome. Int J Cardiol 2019; 278:28-33. [PMID: 30266354 DOI: 10.1016/j.ijcard.2018.09.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Symptoms of anxiety are highly prevalent among survivors of an acute coronary syndrome (ACS), but do not necessarily indicate an anxiety disorder. The extent to which symptoms of anxiety or a diagnosis of this condition impacts hospital readmission and post-discharge mortality among patients with an ACS remains unclear. METHODS We used data from 1909 patients discharged from six hospitals in Massachusetts and Georgia after an ACS. Moderate/severe symptoms of anxiety were defined based on responses to a Generalized Anxiety Disorder questionnaire during the patient's index hospitalization. The diagnosis of an anxiety disorder was based on review of hospital medical records. Multivariable adjusted Poisson regression and Cox proportional-hazards models were used to estimate the risk of 30-day hospital readmissions and 2-year total mortality. RESULTS The mean age of the study population was 61 years, two thirds were men, and 78% were non-Hispanic whites. In this population, 10.4% had a documented diagnosis of an anxiety disorder, 18.8% had moderate/severe symptoms of anxiety, and 70.8% had neither a diagnosis nor symptoms of anxiety. Neither a diagnosis of an anxiety disorder nor symptoms of anxiety were associated with 30-day all-cause or cardiovascular-related rehospitalizations. Patients with an anxiety disorder (multivariable adjusted HR = 1.95, 95%CI = 1.11-3.42) were at greatest risk for dying during the 2-year follow-up period. CONCLUSIONS We identified patients with an anxiety disorder as being at greater risk for dying after hospital discharge for an ACS. Interventions may be more appropriately targeted to those with a history of, rather than acute symptoms of, anxiety.
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Affiliation(s)
- Hoang Tran
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, United States of America
| | - Nancy Byatt
- Department of Psychiatry, University of Massachusetts Medical School, United States of America
| | - Nathaniel Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, United States of America
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, United States of America
| | - Randolph S Devereaux
- Department of Community Medicine, Mercer University School of Medicine, United States of America
| | - Jane Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, United States of America
| | - Catarina Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, United States of America
| | - Robert Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, United States of America.
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Increase in white blood cell count is associated with the development of atrial fibrillation after an acute coronary syndrome. Int J Cardiol 2019; 274:138-143. [PMID: 29936044 DOI: 10.1016/j.ijcard.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Evidence linking an elevated white blood cell count (WBCC), a marker of inflammation, to the development of atrial fibrillation (AF) after an acute coronary syndrome (ACS) is limited. We examined the association between WBCC at hospital admission, and changes in WBCC during hospitalization, with the development of new-onset AF during hospitalization for an ACS. METHODS Development of AF was based on typical ECG changes in a systematic review of hospital medical records. Increase in WBCC was calculated as the difference between maximal WBCC during hospitalization and WBCC at hospital admission. Multiple logistic regression analysis was used to adjust for several potentially confounding demographic and clinical variables in examining the association between WBCC, and changes over time therein, with the occurrence of AF. RESULTS The median age of study patients (n = 1325) was 60 years, 31.8% were women, and 80.1% were non-Hispanic whites. AF developed in 7.3% of patients with an ACS. Patients who developed AF, as compared with those who did not, had a similar WBCC at admission, but a greater increase in WBCC during hospitalization (6.0 × 109 cell/L vs. 2.7 × 109 cell/L, p < 0.001). After adjusting for several potentially confounding factors, an increase in WBCC was associated with the development of AF. This association was observed in patients with different ACS subtypes, types of treatment received, and according to time of acute symptom onset. CONCLUSION Increase in the WBCC during hospitalization for an ACS should be further studied as a potentially simple predictor for new-onset AF in these patients.
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Barriers to Healthcare Access and to Improvements in Health-Related Quality of Life After an Acute Coronary Syndrome (From TRACE-CORE). Am J Cardiol 2018; 122:1121-1127. [PMID: 30107903 DOI: 10.1016/j.amjcard.2018.06.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/11/2018] [Accepted: 06/25/2018] [Indexed: 01/22/2023]
Abstract
Little is known about how barriers to healthcare access affect health-related quality of life (HRQOL) after an acute coronary syndrome (ACS). In a large cohort of ACS survivors from 6 medical centers in Massachusetts and Georgia enrolled from 2011 to 2013, patients were classified as having any financial barriers, no usual source of care (USOC), or transportation barriers to healthcare based on their questionnaire survey responses. The principal study outcomes included clinically meaningful declines in generic physical and mental HRQOL and in disease-specific HRQOL from 1 to 6 months posthospital discharge. Adjusted relative risks (aRRs) for declines in HRQOL were calculated using Poisson regression models, controlling for several sociodemographic and clinical factors of prognostic importance. In 1,053 ACS survivors, 29.0% had a financial barrier, 14.2% had no USOC, and 8.7% had a transportation barrier. Patients with a financial barrier had greater risks of experiencing a decline in generic physical (aRR 1.48, 95% confidence interval [CI] 1.17, 1.86) and mental (aRR 1.36, 95% CI 1.07, 1.75) HRQOL at 6 months. Patients with 2 or more access barriers had greater risks of decline in generic physical (aRR 1.53, 95% CI 1.20, 1.93) and mental (aRR 1.50, 95% CI 1.17, 1.93) HRQOL compared with those without any healthcare barriers. There was a modest association between lacking a USOC and experiencing a decline in disease-specific HRQOL (aRR 1.46, 95% CI 0.96, 2.22). Financial and other barriers to healthcare access may be associated with clinically meaningful declines in HRQOL after hospital discharge for an ACS.
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21
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Erskine NA, Waring ME, McManus DD, Lessard D, Kiefe CI, Goldberg RJ. Barriers to Healthcare Access and Long-Term Survival After an Acute Coronary Syndrome. J Gen Intern Med 2018; 33:1543-1550. [PMID: 29998434 PMCID: PMC6108984 DOI: 10.1007/s11606-018-4555-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/25/2018] [Accepted: 06/11/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Barriers to healthcare are common in the USA and may result in worse outcomes among hospital survivors of an acute coronary syndrome (ACS). OBJECTIVE To examine the relationship between barriers to healthcare and 2-year mortality after hospital discharge for an ACS. DESIGN Longitudinal study. SETTING Survivors of an ACS hospitalization were recruited from 6 medical centers in central Massachusetts and Georgia in 2011-2013. PATIENTS Study participants with a confirmed ACS reported whether they had a financial-related healthcare barrier, no usual source of care, or a transportation-related healthcare barrier around the time of hospital admission. INTERVENTIONS None. MEASUREMENTS Cox regression analyses calculated adjusted hazard ratios (aHRs) for 2-year all-cause mortality for the three healthcare barriers while controlling for several demographic, clinical, and psychosocial characteristics. RESULTS The mean age of study participants (n = 2008) was 62 years, 33% were women, and 77% were non-Hispanic white. One third of patients reported a financial barrier, 17% lacked a usual source of care, and 12% had a transportation barrier. Five percent (n = 100) died within 2 years after hospital discharge. Compared to patients without these barriers, those lacking a usual source of care and with barriers to transportation experienced significantly higher mortality (aHRs 1.40, 95% CI 1.30 to 1.51 and 1.46, 95% CI 1.13 to 1.89, respectively). Financial barriers were not associated with all-cause mortality (aHR 0.79, 95% CI 0.60 to 1.06). LIMITATIONS Observational study with other unmeasured potentially confounding prognostic factors. CONCLUSIONS Absence of an established usual source of care and inconsistent transportation availability were associated with a higher risk for dying after an ACS. Patients with these barriers to follow-up care may benefit from more intensive follow-up and support.
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Affiliation(s)
- Nathaniel A Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Molly E Waring
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Allied Health Sciences, College of Agriculture, Health and Natural Resources, University of Connecticut, Storrs, CT, USA
| | - David D McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
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Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4483] [Impact Index Per Article: 747.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Nobel L, Jesdale BM, Tjia J, Waring ME, Parish DC, Ash AS, Kiefe CI, Allison JJ. Neighborhood Socioeconomic Status Predicts Health After Hospitalization for Acute Coronary Syndromes: Findings From TRACE-CORE (Transitions, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education). Med Care 2017; 55:1008-1016. [PMID: 29016395 PMCID: PMC5687991 DOI: 10.1097/mlr.0000000000000819] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the influence of contextual factors on health-related quality of life (HRQoL), which is sometimes used as an indicator of quality of care, we examined the association of neighborhood socioeconomic status (NSES) and trajectories of HRQoL after hospitalization for acute coronary syndromes (ACS). METHODS We studied 1481 patients hospitalized with acute coronary syndromes in Massachusetts and Georgia querying HRQoL via the mental and physical components of the 36-item short-form health survey (SF-36) (MCS and PCS) and the physical limitations and angina-related HRQoL subscales of the Seattle Angina Questionnaire (SAQ) during hospitalization and at 1-, 3-, and 6-month postdischarge. We categorized participants by tertiles of the neighborhood deprivation index (a residence-census tract-based measure) to examine the association of NSES with trajectories of HRQoL after adjusting for individual socioeconomic status (SES) and clinical characteristics. RESULTS Participants had mean age 61.3 (SD, 11.4) years; 33% were female; 76%, non-Hispanic white; 11.2% had household income below the federal poverty level. During 6 months postdischarge, living in lower NSES neighborhoods was associated with lower mean PCS scores (1.5 points for intermediate NSES; 1.8 for low) and SAQ scores (2.4 and 4.2 points) versus living in high NSES neighborhoods. NSES was more consequential for patients with lower individual SES. Individuals living below the federal poverty level had lower average MCS and SAQ physical scores (3.7 and 7.7 points, respectively) than those above. CONCLUSIONS Neighborhood deprivation was associated with worse health status. Using HRQoL to assess quality of care without accounting for individual SES and NSES may unfairly penalize safety-net hospitals.
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Affiliation(s)
- Lisa Nobel
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Bill M. Jesdale
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Molly E. Waring
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David C. Parish
- Department of Community Medicine, Mercer University, Macon GA
| | - Arlene S. Ash
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jeroan J. Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Hajduk AM, Hyde JE, Waring ME, Lessard DM, McManus DD, Fauth EB, Lemon SC, Saczynski JS. Practical Care Support During the Early Recovery Period After Acute Coronary Syndrome. J Appl Gerontol 2017; 37:881-903. [PMID: 28380706 DOI: 10.1177/0733464816684621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the prevalence and predictors of receipt of practical support among acute coronary syndrome (ACS) survivors during the early post-discharge period. METHOD 406 ACS patients were interviewed about receipt of practical (instrumental and informational) support during the week after discharge. Demographic, clinical, functional, and psychosocial predictors of instrumental and informational practical support were examined. RESULTS 81% of participants reported receiving practical support during the early post-discharge period: 75% reported receipt of instrumental support and 51% reported receipt of informational support. Men were less likely to report receiving certain types of practical support, whereas married participants and those with higher education, impaired health literacy, impaired activities of daily living, and in-hospital complications were more likely to report receiving certain types of practical support. CONCLUSION Receipt of practical support is very common among ACS survivors during the early post-discharge period, and type of support received differs according to patient characteristics.
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Goldberg RJ, Gore JM, McManus DD, McManus R, Tisminetzky M, Lessard D, Gurwitz JH, Parish DC, Allison J, Hess CN, Wang T, Kiefe C. Race and place differences in patients hospitalized with an acute coronary syndrome: Is there double jeopardy? Findings from TRACE-CORE. Prev Med Rep 2017; 6:1-8. [PMID: 28210536 PMCID: PMC5300696 DOI: 10.1016/j.pmedr.2017.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/18/2017] [Accepted: 01/22/2017] [Indexed: 11/10/2022] Open
Abstract
The objectives of this longitudinal study were to examine differences between whites and blacks, and across two geographical regions, in the socio-demographic, clinical, and psychosocial characteristics, hospital treatment practices, and post-discharge mortality for hospital survivors of an acute coronary syndrome (ACS). In this prospective cohort study, we performed in-person interviews and medical record abstractions for patients discharged from the hospital after an ACS at participating sites in Central Massachusetts and Central Georgia during 2011–2013. Among the 1143 whites in Central Massachusetts, 514 whites in Central Georgia, and 277 blacks in Central Georgia, we observed a gradient of socioeconomic position with whites in Central Massachusetts being the most privileged, followed by whites and then blacks from Central Georgia; similar gradients pertained to psychosocial vulnerability (e.g., 10.7%, 25.1%, and 49.1% had cognitive impairment, respectively) and to the hospital receipt of all 4 evidence-based cardiac medications (35.5%, 18.1%, and 14.4%, respectively) used in the acute management of patients hospitalized with an ACS. Multivariable adjusted odds ratios (95% confidence intervals) for the receipt of a percutaneous coronary intervention for whites and blacks in Georgia vs. whites in Massachusetts were 0.57 (0.46–0.71) and 0.40(0.30–0.52), respectively. Thirty-day and one-year mortality risks exhibited a similar gradient. The results of this contemporary clinical/epidemiologic study in a diverse patient cohort suggest that racial and geographic disparities continue to exist for patients hospitalized with an ACS. We observed a gradient of socio-economic position, treatment practices, and dying. Interplay of race and place with treatment practices and post discharge outcomes. Racial and geographic disparities continue to exist for patients after an ACS.
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Affiliation(s)
- Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Joel M Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Richard McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Mayra Tisminetzky
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - David C Parish
- Department of Community Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Jeroan Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Connie Ng Hess
- University of Colorado Denver - Anschutz Medical Campus, Denver, CO, United States
| | - Tracy Wang
- Duke Clinical Research Institute, Durham, NC, United States
| | - Catarina Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
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Huang W, FitzGerald G, Goldberg RJ, Gore J, McManus RH, Awad H, Waring ME, Allison J, Saczynski JS, Kiefe CI, Fox KAA, Anderson FA, McManus DD. Performance of the GRACE Risk Score 2.0 Simplified Algorithm for Predicting 1-Year Death After Hospitalization for an Acute Coronary Syndrome in a Contemporary Multiracial Cohort. Am J Cardiol 2016; 118:1105-1110. [PMID: 27561191 DOI: 10.1016/j.amjcard.2016.07.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/10/2016] [Accepted: 07/10/2016] [Indexed: 12/22/2022]
Abstract
The GRACE Risk Score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome (ACS). GRACE Risk Score 2.0 substitutes several variables that may be unavailable to clinicians and, thus, limit use of the GRACE Risk Score. GRACE Risk Score 2.0 performed well in the original GRACE cohort. We sought to validate its performance in a contemporary multiracial ACS cohort, in particular in black patients with ACS. We evaluated the performance of the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality in 2,131 participants in Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE), a multiracial cohort of patients discharged alive after an ACS in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia. The median age of study participants was 61 years, 67% were men, and 16% were black. Half (51%) of the patients experienced a non-ST-segment elevation myocardial infarction (NSTEMI) and 18% STEMI. Eighty patients (3.8%) died within 12 months of discharge. The GRACE Risk Score 2.0 simplified algorithm demonstrated excellent model discrimination for predicting 1-year mortality after hospital discharge in the TRACE-CORE cohort (c-index = 0.77). The c-index was 0.94 in patients with STEMI, 0.78 in those with NSTEMI, and 0.87 in black patients with ACS. In conclusion, the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality exhibited excellent model discrimination across the spectrum of ACS types and racial/ethnic subgroups and, thus, may be a helpful tool to guide routine clinical care for patients with ACS.
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Affiliation(s)
- Wei Huang
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Gordon FitzGerald
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Richard H McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hamza Awad
- Department of Community Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Molly E Waring
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jeroan Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Keith A A Fox
- Center for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Frederick A Anderson
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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